Читать книгу The Vagina Bible - Jen Gunter - Страница 9

CHAPTER 1

The Vulva

NO WOMAN HAS EVER BENEFITED by learning less about her body.

The vulva is the ultimate multitasker—it is the most important organ for sexual pleasure, it protects the tissues at the vaginal opening, it is built to handle the irritation of urine and feces, and it can deliver a baby and heal as if nothing happened. And do it all again.

Oh, yeah—and multiple orgasms.

The penis and scrotum have nothing on the vulva.

The problem? The vulva is often neglected. A lot of this vulvar neglect is a result of patriarchal society’s lack of investment in and fear of female sexual pleasure. When we exclude the vulva from conversations about women’s bodies and sexuality, we erase the organ responsible for female orgasm. We also make it harder for women to communicate with their health care providers.

The most important basic anatomic point of the lower genital tract: the vulva is the outside (where your clothes touch your skin) and the vagina is the inside. The transition zone between the vulva and vagina is called the vestibule.

The main structures of the vulva are as follows (refer to Image 1 on page 2):

• Mons

• Labia majora (outer lips)

• Labia minora (inner lips)

• The glans clitoris (the part of the clitoris that is visible)

• The clitoral hood

• The vestibule

• The opening of the urethra (the tube that drains the bladder)

• The perineum (the area between the vestibule and the anus)

We are also going to invite the anus to the vulva’s party, even though technically it is part of the gastrointestinal tract and not the reproductive tract. Many vulvar conditions affect the anus, and women often have a hard time getting help for anal concerns—doctors often hear “woman” and “down there” and deflect to the gynecologist. Some women are also interested in information about anal sex, and fecal incontinence can be a consequence of vaginal delivery.

The History of Clitoral Neglect

Going way back, medically speaking—as in Hippocrates (although there is a belief among many academics that Hippocrates wasn’t even a real person) —male physicians rarely performed pelvic exams on women or even dissected female cadavers, as it was considered inappropriate or insensitive for a man to touch a woman outside of a marital relationship. As there were no female physicians, everything first written about women’s bodies in ancient medical textbooks and taught to the first physicians was what women and midwives passed along to men, who in turn interpreted the information as they saw fit. So medicine has been steeped in man-splaining from the start.

Most ancient physicians, probably like many other males of the time, were unsure of the role of the clitoris and likely thought it unimportant. This stands in sharp contrast to the anatomic glory of the penis. In medicine, all body surfaces are assigned a front or back, which we call ventral (front) or dorsal (back). If you look at a person standing straight in a neutral position (arms at the side and palms facing forward), the face, chest, and palms of the hands are on the ventral side, and the back and the back of the hands are dorsal. This convention is applied differently to the penis, because of course it is. The neutral stance for a man, according to the anatomists of old, was a massive, skyward-pointing erection. Except, of course, men don’t walk around with constant erections, and so when you look at a man in what most people would consider the resting state—meaning a flaccid penis—the part that faces you is not the “front” of the penis but actually the dorsal or back surface, and the undersurface is the ventral.

It’s not really a small point; it is a wonderful (in a tragicomic kind of way) encapsulation of how society, including medicine, is obsessed with erections, while the clitoris barely registers as a footnote. The clitoris, when it was considered by ancient physicians at all, was believed to be the female version of the penis. But lesser. (I’m sorry, but the organ, capable of multiple orgasms, that only exists for pleasure is not lesser. It is the gold standard.) Clitoral neglect wasn’t confined to medicine. Think about all those ancient Greek statues with defined scrotum and penises (although the penises are on the small side because sexuality was apparently at odds with intellectual pursuits and so a big brain, not a big penis, was the ideal). The vulvas of the time were but mysterious mounds concealed by crossed legs.

Around 1000 A.D., Persian and Arab physicians began to take more interest in the clitoris, but given the constraints imposed on male physicians touching a naked woman or even a female cadaver, work was slow. By the end of the 17th century, descriptions of female anatomy, including the clitoris, were quite accurate, anatomically speaking. Some anatomists who made these advancements are memorialized in the names of the structures they accurately described—Gabriele Fallopio (fallopian tubes; also invented the first condom and studied it in a clinical trial!) and Caspar Bartholin (Bartholin’s glands).

By 1844, the anatomist Georg Ludwig Kobelt published such detailed work that his anatomic descriptions of the clitoris rival those we have today. However, his work was essentially ignored (as was almost everything that had led up to it), likely due to a combination of the expansion of Victorian beliefs (essentially the dangers of female sexuality) and Freud popularizing the false belief that the clitoris produced an “immature” orgasm.

For many years, discussing female sexuality in the doctor’s office was taboo, but that oppression is not a failing unique to medicine. In 1938, a Los Angeles teacher, Helen Hulick, was held in contempt of court for daring to show up in pants to testify as a witness and for refusing to change into a dress when the male judge insisted. She was given a five-day jail sentence. Much of women’s health, especially sexual health, was deemed unimportant or irrelevant because that is how women were viewed.

Physicians in the ’20s and ’30s truly believed the vagina was filled with dangerous bacteria. Of course, that idea is absurd, and you don’t need a medical degree to reach that conclusion. If the vagina were perpetually in such a state of infectious near-catastrophe, women would never have survived, evolutionarily speaking. The narrative of a dirty vagina did, however, fit the societal goal of female oppression.

A male-dominated profession, a male-dominated society with little interest in women’s experiences and opinions about their own bodies, a penis-centric view of female sexuality, and the belief propagated by Freud’s work that the clitoris was unimportant are a lot of obstacles to overcome. The clitoris, being largely internal, is practically also harder to study than the penis. Eventually, anatomic studies using female cadavers to dissect the clitoris were allowed, but it is important to note the limitations of the work. Most cadaveric studies involve a few bodies; seven is considered a lot. Cadavers are expensive and not readily available. Many cadavers are also older subjects, and clitoral volume reduces after menopause; in one cadaveric study, all subjects were between seventy and eighty years old. The preservation process also distorts the clitoris. Before the advent of MRI (magnetic resonance imaging), it wasn’t really possible to know exactly how the clitoris in a living woman was positioned or how it engorges with blood in response to sexual stimulation.

Anatomic knowledge has come a long way. While I don’t remember each anatomy lecture from medical school and residency, I still have my textbooks. Two were printed in 1984 and another in 1988. The two that are specific for OB/GYN are anatomically correct clitoris-wise, but the general anatomy book (1984) devoted three pages of illustrations (two in color) to the penis, with the clitoris relegated to an inset image in an upper outer corner—and the entire structure is the worst shade of puce. It’s also called a “miniature penis.”

As if.

The Clitoris

The clitoris has one purpose: sexual pleasure. It is the only structure in the human body solely designed for pleasure.

Structurally, think of the clitoris as an inverted Y, but each side has two sets of arms. The very tip of the Y is folded and is the only visible part. This is known as the glans, which is partially covered by the prepuce (clitoral hood). The inverted Y sits on top of the urethra, with the two arms draped over either side.

Beneath the surface, you find the following:

• THE BODY: The part of the inverted Y that folds on itself. It is 2–4 cm in length. Connected to the pubic bone with a ligament.

• THE ROOT: Connects the clitoral body with the crura. The erectile parts of the clitoris converge here. It is very important for sensation because it’s very superficial (beneath the skin right above the urethra).

Image 2: Clitoral anatomy. ILLUSTRATION BY LISA A. CLARK, MA, CMI.

• THE CRURA (“CRUS” IS THE SINGULAR): The outside arms of the inverted Y (some people also describe them as looking like the arms of a wishbone). They are 5–9 cm in length, and there is one on each side, approximately beneath the labia majora.

• THE CLITORAL (ALSO CALLED VESTIBULAR) BULBS: The inside arms of the inverted Y. They are 3–7 cm in length and are in contact with the outside of the urethra and vagina.

Because the clitoris is so intimate with the urethra and the lower walls of the vagina, many experts feel a better terminology is the clitorourethrovaginal complex.

All parts of the clitoris are involved in sexual sensation and all parts are erectile, meaning they can engorge with blood, becoming firmer. The glans has the highest concentration of nerves and the least amount of erectile tissue. The body and the crura have the most erectile tissue. The presence of sexually responsive nerves and erectile tissue in all parts of the clitoris likely explains why there are reports of women who were born without a clitoral glans, women who have had surgery that removed the urethra (and likely parts of the clitoris that were connected), and women who have endured female genital mutilation (FGM) who are still able to achieve orgasm. This tells us that all of the clitorourethrovaginal complex is capable of sexual sensation. It means there are a lot of sexually responsive areas to explore. This can be for fun, discovering the results from sexually stimulating various areas (sexploration at its best). This can also be in search of orgasm. For some women the glans clitoris may not be the best pathway to orgasm, so moving sexual stimulation to other areas may help achieve orgasm. This information about the clitoris being so much more than the glans may also give hope to women who have endured injury to their clitoral glans—for example as a consequence of cancer surgery or FGM—although obviously, it does not make up for the loss.

The Labia and Mons

The mons and the two sets of labia, the labia majora and labia minora, exist to enhance sexual pleasure and to protect the vestibule (vaginal opening).

The mons is the area of skin and fatty tissue from just above the pubic bone down to the clitoral hood—the fat pad raises the tissue a little, and this may offer a mechanical barrier of sorts. The labia majora are folds of hair-bearing skin and fatty tissue that extend from the mons to just below the vestibule. They are filled with different kinds of glands. They are generally 7–12 cm in length, but if yours are larger or smaller, that is just fine.

The labia minora do not have fat, but they have erectile tissue, so they engorge or swell with sexual stimulation. At the level of the glans, they divide into two folds; the top forms the clitoral hood (prepuce) while the bottom is called the frenulum and sits under the glans. The glans of the clitoris is nestled between these folds, so traction on the labia minora enhances sexual pleasure. The labia minora are filled with specialized nerve endings important for sexual response, especially along their edge. They are capable of distinguishing touch on a very fine scale.

The labia minora may or may not protrude beyond the labia majora, and there is no “normal” size or shape. They can range from < 1 cm in width to 5 cm, but wider would not be considered medically abnormal. They may be asymmetric—think of them as sisters, not twins.

The Skin of the Vulva

Under the microscope, all skin looks like a brick wall—cells are stacked on top of each other in layers upon multiple layers. The very bottom layer has specialized cells called basal cells. Basal cells produce new skin cells that are pushed up towards the top, like a conveyor belt. The cells develop as they move upwards, producing a protein called keratin that serves as waterproofing and makes the cells tougher so they can resist injury. At the surface, the skin cells release fatty substances that provide protection against trauma and infection, as well as trapping moisture. The cells in the top layer are dead, and they are brushed off with everyday wear and tear, or with trauma. A new layer is replaced approximately every thirty days.

The mons and labia majora have sweat glands (eccrine glands) that secrete perspiration through pores directly onto the skin. They also have vellus hair (fine, peach fuzz–like hair) and pubic hair; both provide a mechanically protective barrier and trap moisture. As each pubic hair is attached to a nerve ending, tugging or friction on the hair may have a role in sexual stimulation.

Inside the hair follicle of each pubic and vellus hair is a sebaceous gland that produces sebum, an oily substance that keeps the skin soft and pliable and contributes to the waterproofing. Pubic hair follicles also have specialized sweat glands called apocrine glands (also found in the armpit) that become active during puberty. They empty a specialized oily sweat with trace amounts of hormones and pheromones onto the hair shaft. Skin bacteria convert the secretions from apocrine sweat glands into odorous compounds, which are responsible for the typical, intense apocrine sweat smell. The true function of the apocrine sweat glands is not known, but as they develop and become functional around puberty and secrete pheromones, it is likely they had or still have some role in sexual attraction.

The skin of the labia minora has fewer layers and less keratin. These skin changes become more pronounced as you move towards the vaginal opening (vestibule). The labia minora has no hair, but it does have sebaceous glands. Less keratin, thinner skin, and no hair makes the labia minora more vulnerable to trauma and irritants.

Secretions from the sebaceous and apocrine glands mix with fatty substances produced by the skin cells and form a layer called the acid mantle—a film on the surface of the skin that helps protect against bacteria, viruses, and other contaminants. The pH of the vulvar skin is around 5.3–5.6, so just slightly acidic (water has a pH of 7.0, which is considered neutral).

Melanin

Skin, hair, and the irises of your eyes all get their color from the pigment melanin, which is produced by specialized skin cells called melanocytes in the basal layer. Interestingly, the vulva has more melanocytes than many other body parts, yet it is the same skin tone as almost everywhere else (with the exception of palms and soles, which can be lighter). Medicine still can’t explain how your back has fewer melanocytes than your vulva but they end up the same or a very similar tone.

While melanin absorbs and reflects ultraviolet light and provides protection from the sun, melanocytes also respond to biological, physical, and chemical stimuli and are part of the immune system.

The Vestibule

The junction between the vagina and the vulva is the vestibule, and the urethra is located in the vestibule. Technically the vestibule is external, but the skin is similar to what you would find in the vagina: it’s mucosal skin, meaning there is very little keratin and the cells are filled with glycogen, a storage sugar. There is also no hair or sebum, so the tissue is primarily protected physically by the labia minora.

There are also two sets of specialized glands—the top pair are Skene’s glands, which are similar to the prostate in men (studies show that they secrete tiny amounts of prostate-specific antigen, or PSA). The Bartholin’s glands sit at the bottom on either side of the vestibule. They both may contribute a small amount of lubrication.

Anal Sphincters

The anus has two muscular rings called the internal and the external sphincter. The mucosa of the anus is highly innervated (full of nerves) because the tissue has to distinguish between solid and liquid stool as well as gas, in addition to coordinating the socially appropriate time for emptying. This rich network of nerves is why some people find anal sex very stimulating. It is also why hemorrhoids or fissures (small breaks in the skin) hurt so very much.

The internal sphincter is the most important in terms of stool continence. It is responsible for about 80 percent of fecal continence.

BOTTOM LINE

• The part of your body that touches your underwear is the vulva; anything inside is the vagina. The vestibule is in between.

• The clitoris is much larger than what you see and is the only organ that exists entirely for pleasure.

• There is no “normal” size for labia minora and labia majora.

• Labia minora, labia majora, and the mons contribute to both sexual pleasure and protection of the vagina opening.

• The pH of the vulvar skin is acidic, between 5.3 and 5.6.